EVERYTHING YOU SHOULD KNOW ABOUT TITLE 33

provided by:provided by:Tennessee Department of Tennessee Department of

Mental Health and Substance Abuse Mental Health and Substance Abuse ServicesServices

Division of Mental Health ServicesDivision of Mental Health ServicesContent guided by Title 33Content guided by Title 33

and TDMHSAS Rule 0940-3-8and TDMHSAS Rule 0940-3-8

• Participants will verbalize an increased knowledge of the laws that relate to the emergency involuntary hospitalization process

• Participants will demonstrate an increased understanding of how an individuals rights might be impacted in an emergency situation

• Participants will learn about resources available to individuals experiencing a behavioral health crisis

OBJECTIVES

Title 33 is the section of Tennessee Code Annotated that pertains to the laws and codes that govern mental health care here in Tennessee.

WHAT IS TITLE 33?

No person shall be deprived of liberty on the grounds that the person has or is believed to have a mental illness, a serious emotional disturbance, a developmental disability, or is in need of service for such a condition except in accordance with the provisions of this title.

TCA §33-3-101

YOUR RIGHTS

Individuals with mental illness, serious emotional disturbance, or developmental disability have the same rights as all others except to the extent that an individual’s rights are curtailed in accordance with Title 33 or other law.

TCA §33-3-101

YOUR RIGHTS

Individuals with mental illness, serious emotional disturbance, or developmental disability shall be provided services or supports, to the extent that facilities, equipment and personnel are available, in accordance with community standards.

TCA §33-3-101

YOUR RIGHTS

• No individual shall be denied the right to dispose of property, execute instruments, make purchases, enter into contractual relationships, give informed consent to treatment, and vote, unless the individual is unable to make decisions or state or federal law allows denial. TCA §33-3-102

• Providers under this title may not discourage or prevent an individual from exercising their right to religious expression. TCA §33-3-126

YOUR RIGHTS

• If you are sixteen (16) years of age or older, you may request that your service provider tell you what records are being maintained and how you can access to them. Upon your written request, a service provider shall permit you, within a reasonable time, to review your record.

• There are certain exceptions to this disclosure which your provider must adhere to.    

TCA §33-3-112

ACCESS TO YOUR RECORDS

This is a request made to a court by an individual who believes they have been unjustly detained or taken into custody asking that a legal review of the custodial authority occur.

If a court determines an individual has been unjustly taken into custody, the court may order the individual be released immediately.

TCA §33-3-801

RIGHT TO FILE FOR WRIT OF HABEAS CORPUS

Your service records shall be kept confidential and shall not be disclosed by any person except in compliance with this part. In order for your family, friends or advocates to get information about your care or treatment you must sign a release form authorizing the service provider to disclose the information to which you have consented.

T.C.A. §33-3-103

CONFIDENTIALITY

Processes

 You or your conservator/guardian may request admission to a hospital or treatment resource for diagnosis, observation and treatment and if an examination by an admitting physician determines that there is a need for hospitalization you may be admitted.

TCA §33-6-201 and TCA § 33-6-202

You may request release from the inpatient facility at any time during your stay but if professionals determine you present a risk of harm to yourself or others they may initiate the involuntary process. TCA §33-6-206

 

VOLUNTARY HOSPITALIZATION

• You or someone you know may be involved in a community based screening process completed by a physician, psychologist or Mandatory Pre-screening Agent (all crisis teams have MPAs).• This may be done at an individuals’ home, an emergency department, jail or other community location.

WHEN SOMEONE IS EXPERIENCING A BEHAVIORAL HEALTH CRISIS

TENNESSEE’S CRISIS DELIVERY SYSTEM

• A qualified mental health professional (QMHP)• Licensed to practice in TN• Who has satisfactorily completed the required TDMHSAS training and designated by the Commissioner

T.C.A. § 33-6-427

WHAT IS A MANDATORY PRE-SCREENING AGENT?

• Psychiatrist• Physician with

expertise in psychiatry• Psychologist with

health service provider designation

• Licensed psychological examiner

• Licensed senior psychological examiner

T.C.A. § 33-1-101 (20)

WHAT IS A QMHP?• Licensed master’s

social worker with two years of mental health experience

• Licensed clinical social worker

• Licensed or certified martial and family therapist

• Licensed professional counselor

• Licensed nurse with a master’s degree in nursing who functions as a psychiatric nurse

If an individual is experiencing signs and/or symptoms of a mental illness or serious emotional disturbance that present a risk of harm to the individual experiencing the symptoms or to others they may be detained without a court order for an unlimited amount of time pending completion of a behavioral health evaluation.

TCA §33-6-401

AN INDIVIDUAL MAY BE DETAINED FOR THE PURPOSE OF A MENTAL HEALTH EVALUATION

Mental illness:A psychiatric disorder, alcohol dependence, or drug dependence, but does not include Intellectual Disability or other developmental disabilities.

T.C.A. § 33-1-101(18)

DEFINITIONS

Serious Emotional Disturbance:A condition in a child who currently or at any time during the past year has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet psychiatric diagnostic criteria, that results in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities and includes any mental disorder, regardless of whether it is of biological etiology.

T.C.A. § 33-1-101(22)

DEFINITIONS

Professionals who have the authority to detain for examination include:• law enforcement, • physician, • psychologist or • a Mandatory Prescreening Agent

T.C.A. § 33-6-402

DETAINING FOR EXAMINATION

A person cannot be deprived of liberty on the grounds that the person is believed to have:

a mental illness,serious emotional disturbance,developmental disability, oris in need of service for such a condition except in accordance with Title 33.

T.C.A. § 33-3-101

DETAINING FOR EXAMINATION

The Process for Emergency Involuntary Psychiatric

Hospitalization

An individual may be admitted and detained by a hospital or treatment resource for emergency diagnosis, evaluation, and treatment IF AND ONLY IF:

T.C.A. § 33-6-403

THE SCREENING PROCESS MAY DETERMINE THE NEED OF EMERGENCY HOSPITALIZATION

An individual:• Has a mental illness or serious emotional

disturbance,• Poses an immediate substantial likelihood of

serious harm because of the mental illness or serious emotional disturbance,

• Needs care, training, or treatment because of the mental illness or emotional disturbance, AND

• All available less drastic alternatives to placement in a hospital or treatment resource are unsuitable to meet their needs.

TO QUALIFY FOR EMERGENCY INVOLUNTARY ADMISSION

IF an individual has:Threatened or attempted suicide or to inflict serious

bodily harm on him/herself ORThreatened or attempted homicide or other violent

behavior ORHas placed others in reasonable fear of violent behavior

and serious physical harm to them ORIs unable to avoid severe impairment or injury from

specific risksAND there is a substantial likelihood that such harm will

occur unless the person is placed under involuntary treatment

THEN the criteria for “substantial likelihood of serious harm” can be met.

T.C.A. § 33-6-501

HOW IS SUBSTANTIAL LIKELIHOOD OF SERIOUS HARM DEFINED?

A Certificate of Need (CON) is a legal document which is required by the court for an individual who is admitted to an inpatient behavioral health treatment resource without the consent of the individual receiving services. To be admitted involuntarily there must be two Certificates of Need completed and approved by the court.

WHAT IS A CERTIFICATE OF NEED?

A Mandatory Pre-screening Agent (MPA) must complete one of the two required CONs for a person with mental illness or serious emotional disturbance to be admitted to a Regional Mental Health Institute (RMHI) or private psychiatric hospital.

MPAs are a part of every state crisis service providers crisis delivery system so if you call crisis you will likely be seen by a MPA.

T.C.A. § 33-6-105

ABOUT THE PROCESS

If a MPA is not available within two hours, then a licensed physician or a licensed psychologist with a health service provider designation may complete the CON.

The physician or psychologist must consult with a crisis team member regarding less restrictive alternatives.

T.C.A. § 33-6-105

IF A MANDATORY PRE-SCREENING AGENT IS NOT AVAILABLE

• If a person is to be admitted to a private facility, at least one (1) of the CONs shall be from a professional who is not an employee of the private facility.

• Employment as a faculty member by a school of medicine at a university or college associated with a hospital is not considered employment by the hospital

T.C.A. § 33-4-107

REQUIREMENT FOR DISINTERESTED PROFESSIONAL

If an individual has a physical disorder that requires immediate care, the individual may be taken to the emergency department for medical treatment before being transported to the psychiatric inpatient facility.

T.C.A. §33-4-104

MEDICAL CONSIDERATIONS

What does this mean?This means that the hospital accepting the person for care and treatment must have enough staff and enough space to adequately meet the needs of the individual being hospitalized. This also means that there may be times that someone in need of emergency involuntary hospitalization is either sent to the next closest state hospital that has an empty bed or has to wait for a period of time for a bed to become available at the nearest state hospital. TCA §33-6-108

AVAILABLE, SUITABLE ACCOMMODATIONS (ASA) REQUIRED

The Sheriff is obligated by Title 33 to provide transportation if a Certificate of Need for Emergency Involuntary Hospitalization has been completed and a confirmation number for an available bed has been provided

The Sheriff may designate a secondary transportation agent(s) for the county such as an ambulance service

T.C.A. §33-6-406 T.C.A. §33-6-901

TRANSPORTATION TO THE INPATIENT PSYCHIATRIC HOSPITAL

If it is determined during the screening process that the person does not require physical restraint or vehicle security, these people may transport the individual to the hospital at the transporter’s expense:– one or more friends– neighbors– mental health professionals

familiar with the person– relatives of the person– member of the clergy T.C.A. § 33-6-901

TRANSPORTATION TO THE HOSPITAL

The person or persons providing transportation must provide proof of current automobile insurance to the sheriff before transportation can occur.

T.C.A. §33-6-901

TRANSPORTATION

• Immediate notice is provided to the court upon admission.

• Probable cause hearing within (5) five working days.

• With court approval, continued stay for up to 15 more days.

• Court may approve indefinite stay after that time.

T.C.A. Section 33-6-421(-423)

COURT PROCESS UPON ADMISSION

Information may be disclosed without the consent of the individual receiving services if it is:

• Necessary to carry out duties under this title• Necessary to assure service/care in least

drastic means that are suitable to the service recipient’s liberty and interests

• A service recipient moves from one service provider to another and exchange of information is necessary for continuity of service

T.C.A. § 33-3-105

LIMITS OF CONFIDENTIALITY

The MPA or the MPA’s designee will:

Assess the availability of alternative services and offer referral, if appropriate and

Follow-up with the individual within 12 hours of the assessment

T.C.A. §33-6-106 MPS Rule Chapter 0940-3-8-.05(9)

IF THE MPA DOES NOT RECOMMEND INPATIENT CARE

• Work with your regular mental health provider to get an expedited appointment.

• Work with the crisis service provider to establish a crisis management plan.

• Call your Managed Care Organization for guidance. • Ensure support systems are available as much as

possible. • If concerns persist, ask for a re-evaluation by crisis

and the inpatient provider to determine whether a change in status now results in hospitalization.

IF HOSPITALIZATION IS NEEDED BUT DOESN’T OCCUR- WHAT CAN I DO?

If you or your loved one does not meet emergency hospitalization criteria you may still be able to seek non-emergency admission under Part 5 by filing a complaint with the court clerk.

This requires that the person be examined by two physicians or one physician and one psychologist who both agree that the person needs.

TCA §33-6-504

IF HOSPITALIZATION IS NEEDED BUT DOESN’T OCCUR- WHAT CAN I DO?

• If you are concerned that your loved one might be unable to make sound decisions for themselves due to the symptoms of a mental illness or serious emotional disturbance you may seek a conservator to help the individual with their treatment decisions.

• Conservators/ guardians with power of attorney for health care decisions have the authority to sign someone in for care and treatment if clinically indicated.

Title 34

IF HOSPITALIZATION IS NEEDED BUT DOESN’T OCCUR- WHAT CAN I DO?

Mental Health Declaration for Treatment TCA §33-6-1001

http://www.state.tn.us/mental/t33/DHMT_FORM.pdf

The DMHT is a legal document where individuals can write down their wishes in case of a mental health crisis which may include:

• The mental health treatments and medications that are okay with them and any that are not okay.

• What it looks like when the individual is in a mental health crisis and need help.

• Which hospitals and which mental health agencies are preferred.

TCA §33-6-1001

WHAT IS A MENTAL HEALTH DECLARATION FOR TREATMENT?

Even though mental health professionals will attempt to conform to the wishes of the individual as outlined in the DMHT, those wishes may be overridden if emergency involuntary psychiatric hospitalization is required or the individuals life or health is at risk .

TCA §33-6-1006

DECLARATION FOR MENTAL HEALTH TREATMENT

• Generally, the physician or other service provider will follow the Declaration only when you lack capacity to make informed mental health treatment decisions. TCA §33-6-1002

• A Declaration is not related to payment for services and cannot require hospitalization in the absence of medical necessity. When completing a Declaration, you should consider the limitations of your insurance benefits.

TCA §33-6-1012

DMHT FACTS

A declaration for mental health treatment is good for two (2) years, for a lesser period if so stated, or until revoked, whichever is sooner. TCA §33-6-1003

A declaration is effective only if it is signed by the individual creating the declaration and two (2) competent adult witnesses and is not signed on the premises of a mental health service provider. TCA §33-6-1004

DMHT FACTS

•  If the physician or other provider is unwilling at any time to comply with the declaration for mental health treatment, the physician or provider may withdraw from providing treatment. TCA § 33-6-1005

• The declaration for mental health treatment shall remain in effect and shall be superior to the powers and duties of an appointed conservator with the authority to make mental health treatment decisions. TCA § 33-6-1007

DMHT FACTS CONTINUED

If Crisis Services are needed

Statewide Toll free Crisis Number1-855-CRISIS1 (1-855-274-7471)

National Suicide Prevention Lifeline

1-800-273-TALK(8255)

Always call 911 if life or death emergency

Sejal West, MA – Assistant Commissioner, Division of Mental Health Services

Melissa Sparks, RN, MSN – TDMHSAS Director of Crisis Services and Suicide Prevention

PRESENTERS